At this point in time many would agree that ICD-10 implementation can be considered a money pit. Because of the cost increases, extensive training time and workflow process changes required of organizations, some would say that ICD-10 has become a wallet drainer. Change is good, and with ICD-10, change is necessary, but the extent of change depends on your role in healthcare.

While it is imperative that payers and vendors consider the entire ICD-10-CM code set, it is a reality that some providers will have to focus on only a small subset of the classification system. A big question for most is this: Who will be impacted the greatest, and will it be a money pit for you, or a money maker?

Let’s look at the sections of ICD-10-CM that have experienced significant changes, some of which may impact how you consider doing business in the future.


Those providers that deliver babies will see a significant change in coding. Although the integrity of the classification system is intact under ICD-10, the axis that identifies the current episode of care (delivery, antepartum, etc.) has been eliminated. New to ICD-10-CM is the axis for capturing the trimester. The side-by-side illustration below (Table 1) focuses on the diagnosis of severe pre-eclampsia:

Table 1



642.5-  Severe pre-eclampsia


(The fourth digit identifies current episode of care, such as antepartum condition, delivery, etc.)

O14.1  Severe pre-eclampsia

O14.10  Severe pre-eclampsia, unspecified trimester

O14.12  Severe pre-eclampsia, second trimester

O14.13  Severe pre-eclampsia, third trimester

In 2012, new maternal codes were added to indicate weeks of gestation; codes from the Z3A category identify the specific week of gestation during the encounter. Table 2 below provides an illustration of the code range.

Table 2



Z3A.13       13 weeks of gestation of pregnancy




Fracture Treatment

Any providers that deliver care for treatment of fractures will be required to capture a greater level of detail with their diagnoses. In addition to laterality (left/right), coders will apply a seventh character that identifies encounter. For illustrative purposes, let’s consider a patient who is seen in the emergency department after falling. The ED physician makes the diagnosis of a closed, displaced fracture of the head of the right radius. See Table 3 below for a comparison.



Table 3



813.05  Fracture head of radius                 (closed)

S52.12  Fracture of head of radius

S52.121 Displaced fracture of head of right radius

S52.122  Displaced fracture of head of left radius

S52.123  Displaced fracture of head of unspecified radius

S52.124  Nondisplaced fracture of head of right radius

S52.125 Nondisplaced fracture of head of left radius

S52.126  Nondisplaced fracture of head of unspecified radius

The integrity of the classification system is maintained at the fifth character, with both systems classifying a closed fracture of the head of the radius. Further exploration of the code selection in ICD-10-CM reveals the ability to capture a displaced/undisplaced fracture and laterality (right/left). For this case study, the ICD-9-CM code would be 814.05; the tentative ICD-10-CM code would be S52.121.

It is important to note that the coding assignment is incomplete without the seventh character, which captures the encounter. See the following excerpt (Table 4) for seventh characters in ICD-10-CM:

Table 4

A       Initial encounter for closed fracture

D       Subsequent encounter for fracture with   routine healing

S            Sequela


The correct coding assignment for this case would be S52.121A.

If the patient was referred to an orthopedic surgeon for surgical intervention, the code would still be S52.121A for an initial encounter.

If the patient was seen in the physical therapy department the following week for treatment, the correct coding assignment would be S52.121D.

There is a complete listing of all the seventh characters in the ICD-10-CM code set.  The seventh characters allow for classification of open fractures, non-healing (malunion, nonunion) fractures and sequela as a result of a fracture.

These seventh characters also apply to diagnoses related to the injury and to the poisoning chapter in ICD-10-CM. In addition, seventh characters appear in the External Causes of Morbidity chapter.



External Causes

Traditionally, use of external cause (E codes) has been selective, based on reporting requirements and internal data needs. External cause codes provide another level of detail to the “patient’s story.” For example, in the coding illustration above, we would not know the rest of the story without use of E codes. The patient could have suffered the fracture due to an automobile accident, a football game or from falling down the stairs. If the patient suffered a fall from an escalator, Table 5 displays a side-by-side comparison of ICD-9-CM and ICD-10-CM application.

Table 5



E880.0  Fall from escalator

W10.0xxA  Fall from escalator (seventh character for initial encounter)


There is the ability to capture more detail via the place of occurrence, activity and external cause status. For illustrative purposes, let’s assume the documentation states that the patient fell on an escalator in an airport while running to the gate while traveling on vacation. Table 6 provides a coding summary for the external cause classification.

Table 6



E849.6  Accidents occurring in public building

E001.1  Activities involving running

Y92.520  Airport as the place of occurrence of the external cause

Y93.02  Activity, running

Y99.8    Other external status (activity)


This coding illustration demonstrates the expanded place of occurrence codes and an additional section called External Cause Status (Y99), which captures status. The status categories include activities performed for income, volunteerism, leisure or military service.


Although the expanded code set offers enhanced specificity in all chapters, the changes in Chapter 15 (Pregnancy, Childbirth and the Puerperium), Chapter 19 (Injury, Poisoning and Certain Other Consequences of External Cause), and Chapter 20 (External Causes of Morbidity) require more training time for HIM professionals, clinicians (for documentation improvement) and reimbursement teams, as they all want to be able to capture all to which they are entitled with ICD-10. If you fall into any of these categories, prevent the money pit from overflowing; take a good look at your service lines and turn them into money makers! Providers that currently do not report codes from these chapters will find the transition to ICD-10-CM simpler; if that’s the case, today is your lucky day!

About the Author

Maria T. Bounos, RN, MPM, CPC-H, is the Business Development Manager for Regulatory and Reimbursement software solutions for Wolters Kluwer Law & Business.  Maria began her career at Wolters Kluwer Law & Business as a product manager, responsible for product development, maintenance, enhancements and business development and now solely focuses on business development.  She has more than twenty years of experience in healthcare including nursing, coding, healthcare consulting, and software solutions.

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